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CASE. Esen KIYAN, MD Istanbul University Faculty of Medicine Department of Respiratory Disease. 24 y, female, housewife (married and has one child). Complaint: Dyspnea and cough Exertional dyspnea for five years (progressive increase in dyspnea) - PowerPoint PPT PresentationTRANSCRIPT
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CASE
Esen KIYAN, MD
Istanbul University Faculty of Medicine
Department of Respiratory Disease
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Complaint: Dyspnea and cough Exertional dyspnea for five years (progressive increase
in dyspnea) Painful red-purple spots on the hand and foot
finger tips, night sweat, and intermittent fever for the last 1.5 year
Fatigue
Investigated for these complaints (1.5 year ago) ESR: 90mm/hour, CRP 41mg/L Hb 10g/dL, Hct %35 ANA and RF (-), c and p-ANCA (-)
24 y, female, housewife (married and has one child)
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Past history:
Jaundice at age 13
Abortion due to intrauterine growth retartation
Family history: nonspecific
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Investigated at Internal Medicine and Rheumatology clinics and specific diagnosis (-). No further investigatione because of pregnancy.
Complaints continued after the delivery (dyspnea, painful spots at the finger tips of hand and foot, intermittent fever,fatigue).
For the last five months dry cough and palpitation, for the last three months weight loss (10kg) Admission to an outpatient clinic
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Chest-X-Ray
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ENT examination: Normal
High ESR 18 Eylül 2007 90mm/hour26 Eylül 2007 110mm/hour
Anemia (Hb 9g/dL, Hct %30)
Urine examination:Normal Thyroid function tests: Normal
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C3-C4: normalAnti-Jo1Anti-RNPAnti-Scl70Anti-SmAnti-SS-A(Ro)Anti-SS-B(La)p ve c-ANCARF ve ANA
NEGATIVE
Anti dsDNA
Anti CCP
Anticardiolipin
(IgG ve M)
NEGATIVE
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For fever of unknown etiology
Wright (-)Gruber Widal (-)Abdominal US: Normal
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During outpatient evaluation
Flantadin tb LABA+ICS LTA Geralgine K Antibiotics tried
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Admission to a chest clinic
Physical examination: painful red spots on hand finger tips, Respiratory system findings normal
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LABORATORY FINDINGS
ESR: 62 mm/saat CRP: 39 mg/L
Leucocyte: 5000 /µl (%61 PNL, %31 Lymp)
Hb: 9.8 g/dL Hct: %30.4 PLT: 246000/µl MCV: 80.1 µm3 MCH: 25.9 pg MCHC: 32.3 g/dL
BUN: 13 mg/dl Creatinin: 0.9 mg/dl Sodium: 140 mmol/L Potassium: 4 mg/dl Calcium: 8,9 mg/dl Glucose: 67mg/dl LDH: 122 U/L ALP: 260 U/L AST:12 U/L ALT:9 U/L GGT: 12 U/L T.Protein:6.7g/dl Albumin:4.4 g/dl
ECG:sinusal tachycardia
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Lung Function Tests
FVC 2050 ml (%61)
FEV1 2040 ml (%70)
FEV1/FVC %100
MEF25-75 3820 ml (%95)
DLCO: %70, room air SaO2 SaO2%96
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What is your diagnosis?
1. Vasculitis
2. Connective tissue diseases
3. ILD/Sarcoidosis
4. Pulmonary hemosiderosis
5. Other
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Lung CT
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Which investigation do you choose ?
1. Echocardiography
2. Bronchoscopy
3. Open lung biopsy
4. Biopsy from skin lesions
5. Perfusion lung scanning
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D-Dimer:8.80µg FEU/ml (N <0.5)
Perfusion lung scanning: Irregular perfusion at both lung bases
(low probability for PE)
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EBL (-), mucosa hyperemic and fragile, and increased capillarity
Mucosa biopsy:
- Subepithelial neovascularization and edema
Bronchial lavage
- smear negative for ARB (-), culture (-)
- Nonspecific cultures and cytology (-)
BRONCHOSCOPY
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Anemia, painful spots at the finger tips of hands BP:100/70mmHg, Pulse:110/dk, Respiratory rate:
18, SaO2%96 Respiratory system: no pathologic finding Loud S1, 2/6 middiastolic murmur at mitral area,
3/6 murmur at mesocardiac area
Patient hospitalized (Chronic dyspnea and cough etiology?)
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ECHO:Left atrial mass, 2(+) MR, 3(+) TR,
Severe PHT (PAP 90mmHg)
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POSTOPERATIVE DIAGNOSIS: MYXOMA
Beningn primary cardiac tumor (%80 located in the left atrium)
Dyspnea,palpitation, syncope. Of cases, 30% has fever and weight loss
Lab: Elevated ESR and CRP, leucocytosis and anemia
Heart failure and systemic emboli
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Myxoma and Lung
Pulmonary edema Pulmonary HT Pulmonary emboli Right heart failure